Sometime this month, roughly 20 million Americans will get a letter about their health insurance. Federal law requires it: states must warn Medicaid expansion enrollees, no later than September, that starting January 1, 2027 they will have to document 80 hours a month of work, school, or volunteering, or income of at least 580 dollars a month, or prove they qualify for an exemption, to keep their coverage. Pennsylvania mailed its letters this week, more than 700,000 of them, including 183,000 to Philadelphia alone, in six languages. Montana sent its notice to every Medicaid enrollee in the state, including the seniors, children’s parents, and disabled enrollees the rule does not apply to, leaving families to guess whether it does. And in Nebraska, which started early, the letters phase is already over: on August 1, about 200 people became the first Americans removed from Medicaid under the new work requirement. The deadline the country is counting down to arrives eight weeks after the midterm election. The confusion arrives now.
What the Law Requires
The work requirement comes from the 2025 Republican reconciliation law, the same statute behind the SNAP food aid cuts and student loan changes this newsletter has documented all year. It applies to adults covered through the Affordable Care Act’s Medicaid expansion, roughly 20 million people across the 43 states, including Washington, D.C., that must implement it. It does not apply to children, people on Medicare, or people who qualify for Medicaid through a disability pathway, and the law exempts people with disabilities or serious illness, parents of young children, caregivers, and several other groups. To stay covered, everyone else must show 80 hours a month of work, at least half-time school, job training, or volunteering, or monthly income of at least 580 dollars, checked at application and at least every six months at renewal. Supporters, citing congressional estimates, say the requirement saves the federal government 325 billion dollars over ten years. That savings has to come from somewhere, and the research record is clear about where: previous work requirements did not increase employment. They reduced enrollment.
Arkansas Already Ran This Experiment
This is not a prediction argument; it is a memory argument. When Arkansas imposed a Medicaid work requirement in 2018, during the first Trump administration, 18,000 adults lost coverage in seven months, one in four of everyone subject to the rule, per the Center on Budget and Policy Priorities. Researchers found no measurable effect on employment. Most people who lost coverage were working or exempt; they lost it because they did not know about the rule or could not navigate the paperwork. Georgia, the only state running a work requirement before this year, has enrolled only a small fraction of the people projected to be eligible for its Pathways program in nearly three years. The new national estimates carry the same shape at fifty times the scale: the Urban Institute projects up to 7 million people could lose coverage in 2028 from the work requirement, roughly 3 million even if states implement carefully. Estimates cited in NPR’s reporting run from 3 million to 8.6 million by 2028, the higher figure coming from the administration’s own regulatory filing.
Nebraska Went First
Nebraska did not wait for the deadline. It began enforcing the requirement May 1, eight months early, and its Medicaid director, Drew Gonshorowski, told the health policy newsroom Tradeoffs that about 200 people lost coverage on August 1, the first in the nation. His account of why the state went early is worth quoting: “It is an opportunity to build something that can reach out a hand to our membership. Why wait?” He also described what worries him: “You can imagine a world where a state gets that very wrong because you missed that they had a disability, or you missed that they had earned income every month. That’s the thing that keeps me up at night. That is the one scary number.”
Nebraska is, by its own director’s description, close to a best case. It is small, runs its own eligibility system, and can automatically confirm compliance for about three quarters of the roughly 70,000 people subject to the rule. That still leaves up to 28,000 Nebraskans who must prove their status themselves, and the Urban Institute estimates about 25,000 in the state could ultimately lose coverage, more than a third of those subject to the requirement. Advocates say the state’s notices confused people about whether the rules applied to them, and when Tradeoffs tested the state’s Medicaid help line it hit long waits, a dropped call, and trouble reaching the Spanish language line. The state says average waits are ten minutes. Montana began enforcing July 1. Iowa starts December 1. Arkansas, the state with the cautionary history, is running a soft launch: checking compliance since July but disenrolling no one until January.
Forty States in Four Months
Everything above describes the volunteers. The other forty jurisdictions all go live at once on January 1, and the Center on Budget and Policy Priorities’ assessment of their readiness is blunt: states got less than 18 months from the law’s enactment to build data systems that connect Medicaid to school enrollment records, veterans’ disability ratings, SNAP work requirement status, and medical claims; federal guidance arrived late at every step, with the rule detailing implementation issued only in June; and state eligibility offices were already carrying application backlogs and long call center waits before this began. KFF’s survey of state officials found states still waiting on federal definitions for basic terms, including what counts as community service and how to verify that someone is medically frail. Most states are hiring the same vendor, Deloitte, to rebuild their systems on the deadline; six say they will use artificial intelligence to help process the paperwork. CBPP’s conclusion is that the crunch endangers everyone on Medicaid, including children and people with disabilities the rule exempts, because the same overloaded workers and systems process everyone’s renewals. Its projection is specific: millions will lose coverage “not due to ineligibility, but due to preventable administrative failures.”
The Letter Is the System
Which returns to the mail. The statute’s own authors understood that a rule like this lives or dies on whether people understand it, which is why the law requires the September notices, sent by mail plus at least one other channel, explaining how to comply, how to claim an exemption, and what happens if you do neither. The early returns on that safeguard: Pennsylvania’s 700,000 letters went out in six languages this week, a serious effort. Montana’s went to its entire Medicaid population, sowing exactly the confusion the notice was meant to prevent. Nebraska sent tens of thousands of letters, texts, and emails, plus radio and TV ads, and its own advocates still describe widespread uncertainty about who the rules cover. The Arkansas lesson was never that states are careless. It is that when coverage depends on paperwork, the paperwork becomes the eligibility test, and the people who fail paperwork tests are disproportionately the people working irregular hours, moving between addresses, or managing an illness. Most Medicaid enrollees who can work already do, per KFF. The question the next four months will answer is how many of them can prove it to a computer system built in eighteen months.
Where Things Stand
The calendar from here: notices land in mailboxes across the country this month. Iowa begins enforcement December 1. Forty jurisdictions go live January 1, eight weeks after the November 3 election, meaning voters will choose a Congress before the largest Medicaid change since the Affordable Care Act reaches them, and the Congress they choose will be seated as it does. The administration’s own filing puts potential coverage losses as high as 8.6 million people by 2028. Nebraska’s first 200 are already gone, and its own Medicaid director says the number he watches to know whether the system is working is the number of people who appeal. Watch the mail, and watch that number.